Black Swans and Poverty

Here is a copy of the speech I recently gave at Morecambe Food Bank when Heidi Allen MP and Frank Field MP came to be with us and to listen to the community here in Morecambe Bay about our experiences of poverty. There were some incredibly moving testimonies from community commissioners of the poverty truth commission. This was my contribution:

 

First of all I would like to start by saying thank you. Thank you to all of you for being here to talk about these really important issues. Thank you to my friends, Karen, Emily and Daniel for being brave enough to stand up today, to tell your stories and to allow yourselves to vulnerable and to be heard. Thank you to my friend Siobhan for being willing to speak out consistently about the realities that children in your school and this surrounding area are living with, and for doing so, despite unfair and untrue things being said about you in the public domain. Thank you to Annette and the team here at Morecambe Foodbank for your hospitality, generosity and welcome here today and for all the ways in which you provide for people in this community.

 

Thank you to Si Bellamy from the Eden Project – we’re so grateful for the hope that your partnership brings to this area and for the common values we share in wanting to uncover and deal with our deep systemic issues and injustices and co-create an economy and way of being as community that really works for humanity and the planet. Thank you to so many of our friends across the voluntary and public sectors for being here today and demonstrating our sense of unity in working together with our communities. And thank you Heidi Allen and Frank Field for choosing to work across your differences and to come and be with us today and to listen.

 

Today is not only about Morecambe. Morecambe is an amazing town full of wonderful people and there is a huge amount to be celebrated here. In fact, we could be having this same conversation, with similar but different and important communities across the water in Barrow, or over in Scarborough or down in Hastings because these same issues are found everywhere. Today is about coming together to really listen and to the reality of just how complex some of the issues we’re facing really are, like poverty, and the way it intertwines with many other aspects of our lives, for example our health and wellbeing.

 

Until 1791 people in England believed all swans were white. That was until a black swan arrived on these shores, brought here from Australia. Sometimes we can hold extremely fixed positions and ideas in our minds, until we are confronted by something which causes us to see the world differently. One of the truths about poverty is that it is an incredibly complex and wicked problem. And so it doesn’t help to entrench ourselves in our positions and throw stones at one another once those ideas are challenged.”

 

Robert Peston was right in his devastating analysis that we have become divided. So quickly we enter a blame game over poverty. “It’s your fault I’m poor”, “no, it’s your fault you’re poor”. But all this does is create more polarity, more distance between us as we become ever more entrenched in the certainty of our own arguments and perspectives. But that way of being is failing us, the 3 million children living in poverty and the hundreds and thousands of people who are now destitute. Trying to solve complex issues with overly simple questions is landing us in a mess! We want quick answers and we want to fix things but we do not appreciate the unintended violence of our policies and projects because we have not taken the time to listen, to understand or learn together. But when we do, we discover that not all swans are white and we begin to realise that we can longer continue to see the world that way.

 

The theologian, Samuel Wells, speaks of poverty as not being primarily about deficit, a concept that leads us into blame and heroism. Rather, he recognises that it is our dislocation, our isolation, our separation which is the real root cause of our issues. And so, here in Morecambe Bay, not only through the poverty truth commission, with the mantra that “nothing about me without me is for me”, but in many facets of our life together, including in the NHS, where I have the privilege of working both as a GP and as Director of Population Health that it is in togetherness, through relationship in which we are creating the space to build trust, to ask some really difficult questions and in the process we discover the reality of our pain and despair in one hand and in the other, as Barack Obama would say, we hold the audacity of hope, despite it all.

 

There are things to which together we are saying, “Enough now”. Enough now that some children in our communities cannot afford to eat, despite their parents being ‘back in work’ – and we are so grateful for the youth and community projects that open early to ensure kids get breakfast on the way to school and tea on the way home, despite a real struggle for resources. Enough now of the adverse childhood experiences or traumas through which many of our children our living, massively impacting their physical, mental and social health for years to come. Enough now of the reality that some children living in this Bay can expect to live at least 10 years less than children growing up just 6 miles down the road, with a far poorer quality of life along the way. And as we say enough now to those things and many more human and environmental injustices, we discover that the answers are not found in our current opposing political or economic models. Rather we are finding that together we can begin to create new possibilities of how we can re-imagine and build a future that works for every person and the planet.

 

In actual fact, learning to live well together is really difficult. It takes humility, forgiveness, kindness, breaking down hostility and replacing it with love. It means taking a good hard look at ourselves rather than pointing a finger of judgement at others. It means letting go of mechanistic thinking to fix things and embracing the reality of complex living systems. It means recognising that change starting with us. For me that means dealing with my own ego, my wounds, my root needs, my genealogy, my white male privilege, our colonial history and discovering that it is in encountering the ‘other’, someone utterly different to me that I am changed and I encounter in that person, the very face of God.

 

And so not only are we saying “enough now” to things which must change, but won’t change with our current ‘go to’ solutions, we are also finding that “together we can”. Here in Morecambe Bay, through working together as communities, we are seeing many dozens of initiatives emerging, like our food poverty project, our mental health cafes, community choirs and new partnerships forming across the voluntary, faith and public sectors working on issues like addiction and early intervention in neighbourhoods.

 

We are finding that together we can break down walls of division and find kinder ways of building society. Together we can see different perspectives and change our opinions and views. Together we can discover models of business based on mutuality and sustainability. Together we can help each other take more personal and corporate responsibility, whilst recognising how much easier that is for some than others and so together we can create compassionate communities.

 

Together we can face up to the challenges we see in our NHS and social care with the eye-watering savings we are being asked to make. Together we can ensure every child has a great start in life, we can build an education system that works for every child and face up to the growing mental health crisis in our young people.

 

Together we can ensure that our elderly citizens are respected and cared for. Together we can live in streets that are clean and safe, with every person having a warm, dry home to sleep in. Together we can face up to the environmental disasters which lie ahead if we don’t change. Together we can build a social movement for change with a different kind of power and discover a politics and economics that works for every person and the sustainability of the planet, based on self-giving, others-empowering love, empathy and kindness. And as we are here together today, together, through policy and through partnership we can ensure that no child goes hungry and every life matters. So, I am looking forward to listening and to learning together, through our conversations here today. Thank you.”

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A Vision for Population Health and Wellbeing – All Together We Can

If you haven’t yet had the chance to read the Kings Fund’s vision for population health (and it’s the kind of thing that interests you) then I would heartily recommend that you do so. (https://www.kingsfund.org.uk/publications/vision-population-health). It is a real ‘Tour de Force’ and deserves some significant consideration. I like it because it doesn’t hold back from bringing some hard-hitting challenge, but also creates hope of what is possible. 

 

Last week, whilst I was in Hull, I unpacked some of my (many) thoughts about population health, drawing on the wisdom of this report, the significant challenges we face and the opportunity we have to reimagine the future, together with our communities. I was hoping to offer it as a podcast, but it didn’t record well! This is quite a long read, but I hope encapsulates the key issues and gives us plenty to wrestle with and discuss, reflecting on the great piece of work from the Kingsfund. 

 

When it comes to population health, we have to remember, especially when we look at a global stage, that the UK has had some of the best public health in the world. We have so much to be grateful for and have had some incredible breakthroughs in our health and wellbeing over the last 200 years. Consider how our life expectancy has increased, initially through the great improvements in clean water, sanitation and immunisations and then the emergence of the NHS, with free healthcare for all, no matter of ability to pay, and subsequent lifesaving interventions in the areas like hypertension and diabetes – we’ve come a long way, though there is still plenty of work to do! 

 

However, there is a lesson in humility that we need to take from the All Blacks (consistently the greatest sports team in the world). After successive world cups, which they should have won, they had to take a good, long and hard look at themselves and face up to this uncomfortable truth – they were losing! (and I imagine after the mighty victory of the Irish against them recently, they may be having the same conversation again). We have to face up to the fact that right now, in terms of population health, especially around health inequalities, we are losing and we’re losing BIG. 1 in 200 of us is currently homeless. Childhood poverty is increasing year on year and many of our children go hungry on a daily basis. According to the Food Foundation, our poorest 5th of households would have to spend 43% of their entire income to eat the government’s recommended ‘healthy diet’. Much of our housing stock is unfit to live in. Our healthy life expectancy gap between the rich and the poor is nearly 20 years, with a shocking difference between the North and the South. We have a mental health crisis in our young people, with suicide the leading cause of death by some mile in Males under 45. And to top it all, we have a severe shortage of staff in the NHS and our public services which make it actually impossible to continue the level of service required by the heavy target-driven culture of Whitehall. 

 

To continue trying to deliver the same services in the same way, when these issues are so starkly in front of us, is beyond insanity. We simply cannot continue to continue with business as usual and think that we will achieve anything different or new. This is why I like the 4 interlocking pillars the Kingsfund recommend when thinking about population health and I will unpack some thoughts about each one. 

 

The Wider Determinants of Health

 

Before I start on this section, it is really important for me to state that despite what others have at times accused me of, I am not actually a member of any political party and so when I write things which challenge current government policy or praxis I am not trying to score political points. In fact, I believe it is one of the key purposes of (health) leadership to call out when decision making processes are harming the health and wellbeing of the population (whether intentionally or not). Indeed, the same would apply, whoever was in (seeming) power. 

 

When it comes to tackling the issues of population health, dealing with health inequalities and ensuring that the health and wellbeing of all people and the planet is taken into account in every government policy, the current administration is found sorely wanting. No matter what is peddled out about the “successes” of Universal Credit (which I do actually believe was introduced with some good intentions), it is failing and will continue to fail as necessary safeguards are not being put in place. Since the introduction of UC, we have seen a staggering rise in the use of food banks. Families, especially children are going hungry and the financially poorest in our society are not having their basic nutritional needs met. Since 2010, we have seen childhood poverty rise and the health inequalities gap widen. Much of this is owing to the burden of austerity being carried primarily by our poorest communities. In this same time period, we have seen the loss of overall goals for population health and no clear directives or measures to encourage change. In fact, many of the more project and target driven approaches to population health are often the very things that cause a worsening of health inequalities, like child obesity initiatives, because they do not focus on the wider determinants of health like poverty, housing and planning. 

 

On one level, we should applaud Matt Hancock, Secretary of State for Health and Social Care for encouraging the NHS to get into the game of prevention. However, a mirror then needs holding back up to the government to examine what this really means. It is clear that the current ‘rise’ in funding for the NHS, won’t even enable business to continue as usual (and one might argue that’s a good thing, because we need to change business as usual – except for the fact that there is no letting up on the drivers and targets from the Department of Health that continue to maintain the current modus operandi). The £3.4 billion per year increase won’t even touch the hole in our acute hospital trusts, let alone account for the whopping >49% of total cuts from local government (more than £18 billion in total, with more to follow), who are absolutely instrumental in tackling the wider determinants of health and wellbeing. Public Health, which has always been so vital to the work of prevention has been decimated within local governments, who are struggling to keep their statuary services up and running. So, no, it’s not actually that straightforward for the NHS just to now take on the responsibility of prevention, as the social determinants and wider economic issues, including funding aspects, are an absolutely vital component of getting population health right and asking the NHS to do so, simply piles more pressure on an already stretched and burned out workforce. An ending of austerity and an appropriate level of funding is vital if we are to achieve population health, uncomfortable truth for the government, though this may be.

 

Our Choices, Behaviours and Lifestyles

 

There is a worrying rhetoric finding voice that ‘people should just make better choices and take more responsibility for themselves’, but this is simply far less possible for so many of our communities than others, as a direct result of policy decisions and economic models over which they have no power or control. 

 

One one level, no one would argue that each of us has at least some level of responsibility to make positive lifestyle choices, make good decisions about what we put into our bodies and how much exercise we do or don’t take. But we must remember that this is so much easier for vast swathes of our population than others. 

 

There is plenty of evidence though that helps the NHS think about where to focus when it comes to population health management – where we can make the most difference. These areas include: smoking, alcohol, high sugar intake, high blood pressure, atrial fibrillation, high cholesterol (currently hotly debated!), healthy weight and positive mental health. Remember though, Sandro Galea’s work on ubiquitous factors! It is possible to focus in on projects like these and make health inequalities worse! These things cannot be done in isolation, but must be part of a wider vision. The temptation will be for governments to focus on these narrow interventions and claim great statistical significance whilst still not dealing the root issues. 

 

It is in this that again, we need to see the government come up trumps. Targeted and smart taxation can have a massive impact on the choices we make – we know this through the massive breakthrough we’ve seen in smoking in recent years. The same now needs to be applied to the highly influential, powerful and dangerous sugar industry. A best next step, according to Professor Susan Jebb, from Oxford University, would be to put a substantial tax on biscuits and cakes. Like it or not, along with our carb obsession, these are our biggest downfall and if the government are actually serious about tackling our ‘obesity epidemic’ then they need to break any cosy ties with this industry and stop the nonsense about being too much of a nanny state. Public opinion, which apparently hates the nanny state, thinks the smoking intervention was fantastic and the benefit is clear. The role of government is to see what damages our health and work with us to help modify that behaviour. 

 

An Integrated Health and Care System

 

There are plenty of places around the country where we can now begin to see the potential and power of working together differently. In the UK, Wigan, with great leadership from the likes of Kate Ardern, tells a powerful story of how incredible things can happen when population health is owned by everyone and a social movement is born. Manchester, with its devolved budget, political stability and holistically embedded view of population health championed by the Mayor of the City, Andy Burnham is a fine example of how working together differently can really offer some exciting possibilities. He recently said this:

“As Secretary of State for Health, you can have a vision for health services. As Mayor of Greater Manchester, you can have a vision for people’s health. There is a world of difference between the two!”

 

In Morecambe Bay, as an integrated care partnership within the wider Lancashire and South Cumbria ICS, we have already found some huge benefits in working more closely together. It gives us an opportunity to find solutions to the wicked issues we face through collaboration and combined wisdom, rather than through competition and suspicion. 

 

The integration is important at the macro level (where decision making and budgeting occurs), as well as in the micro level in our neighbourhoods. Our Integrated Care Communities in Morecambe Bay are without doubt one the instrumental building blocks we have to reimagining how we can deliver care more effectively for our communities. In each of our 9 areas around the Bay we have teams involving GPs, the hospital trust, social workers, allied health professionals (physios, OTs), police, fire service, community nursing, community and voluntary teams, faith organisations, and councillors working together for the good of our local neighbourhoods. 

 

The Places and Communities we Live in and With

 

Place is hugely important and so is community. Isolation literally kills us. We have certainly found in Morecambe Bay, that choosing to work differently WITH our communities, rather than doing things to them is fundamental in being holistic when it comes to Population Health and Wellbeing. It has meant learning to take our lanyards from around our necks, getting out of our board rooms (where traditionally we take decisions on behalf of people) and embracing humility as we learn to listen to and partner with our communities. One book I have found really helpful, personally has been ‘The Nazareth Manifesto’ by Samuel Wells. He is considered by some to be the ‘greatest living theologian’, and I consider it to be of vital importance for us to think and engage with these issues of heath and wellbeing as widely as possible, including theology, philosophy, sociology and economics, to help challenge and inform the necessary mindset shifts which are needed. Wells writes that for him, the entire Christian story is encapsulated in these 4 words: “God is with us”. Whatever, you happen to believe about God, there is certainly a majority view that if there is a God, he tends to be quite aloof, distant, hierarchical, dominating, controlling and power-crazy, if not seriously vengeful at times – and interestingly, we often refer to some leader-types as having a ‘God complex’! But if God is not like that, but is primarily about being WITH people, not over them, working WITH them rather than doing things to them, that has huge implications on much of western thought and how we set up leadership and governmental institutions! 

 

Hilary Cottam’s book, Radical Help and Jeremy Heiman’s and Henry Timms’ insights in New Power are both vital reading in really engaging with this whole concept. We need to radically embrace the fundamental truth of relationship as an agent for good and change in our society. Our public services have become devoid of real and genuine relationships with our communities. 

 

Over the last 3 years as we have had many conversations around Morecambe Bay, being honest about the financial predicament we find ourselves in (needing to save £120m over the next 5 years, 1/5th of our total budget, whilst still meeting all our targets!) and listening to each other as we try and work out how we can be more healthy and well together, so many beautiful and amazing things have started. These include: mental health cafes, community choirs, the Morecambe Bay poverty truth commission, walking groups, the daily mile in our local schools, new ways of working between the police, council and local communities, the voluntary sector working differently together, dementia befriending, mental health courses in our schools, a new focus on adverse childhood experiences and many many more. 

 

So Where from Here?

 

I believe we find ourselves in an intersectional moment in which we can unlock a very different kind of future than the one we appear to be currently heading for. It is time for deeper listening and a reimagining of how we really might live in a way together that cedes health and wellbeing of humanity and the planet through everything we do. This means we can honour previous ways of doing things, recognising where some of them have been detrimental and contradictory to true population health, letting go of our insanity in the process and find a new, more healthy way forward. It is vital that we consider these four interactive pillars of population health and embed them into every facet of our life together in society. This means ownership and resulting policy change by the government with funding that actually works for the kind of integrated, living and flexible systems we need to co-create. We need communities to find new ways of being well together, take responsibility for our own lifestyles and behaviours, with compassion and kindness for whom this is less than easy.

 

From my perspective this would mean a reimagining of politics – a rediscovery of how we live well together – away from binary competition and white male privilege and towards collaborative inclusivity and equality, based on love, kindness and compassion aka “kenarchy” in which we renegotiate our relationship with power. It would mean a reimagining of economics – a recalibration away from transaction and a ‘use and abuse biopower’ towards a ‘doughnut economics’ in which we learn to live in the sweet spot of environmental sustainability and human justice and mercy. 

 

There are so many things that we have accepted and reports we have ignored. It is time for us to collectively say “enough now” to that which is dividing and killing us and hold together the reality of despair and hope in our communities, as we allow the reality to sink in that together WITH each other, we really can begin to find an altogether better future for us all and the planet. It won’t be easy and means there are many of our own personal ego structures, deep wounds and problematic behaviours that will need healing and changing along the way, but let’s open our eyes and allow new eye light to help us see the future which in our hearts we are longing for. 

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Facing Our Past, Finding a Better Future – Adverse Childhood Experiences

Tweet This week I had the privilege of listening to Prof Warren Larkin, advisor to the Department of Health on Adverse Childhood Experiences. This is something I’ve written about on this blog before and Warren has made me more determined than ever to keep talking about this profoundly important issue. This blog draws on his [Continue Reading …]

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